'When you hear hoofbeats, think of horses not zebras' - the old adage is well-known to GPs but what should you do when faced with a zebra, not a horse? Consultant cardiologist Professor Robert Tulloh and GP Dr Louise Tulloh kick off our new series with their advice on how to catch Kawasaki disease in general practice.

Spinal manipulation 'has no benefit for back pain'

Controversy over the inclusion of spinal manipulation in NICE guidelines on back pain intensified this week after a study showed no benefit when it was added to standard care with painkillers.

The study in patients with acute low back pain presenting in primary care found no difference in the pain scores of those treated with spinal manipulation and analgesics, compared with those receiving analgesics alone.

It casts doubt on NICE advice that GPs consider a course of spinal manipulation in patients with low back pain after prescribing paracetamol, NSAIDs or weak opiods.

All 104 patients in the study – presented at the WONCA Europe conference in Bern, Switzerland this month – received standard care consisting of general advice, regular paracetamol and diclofenac or dihydrocodeine as required over the six months of the study.

Patients who also received spinal manipulation had only a non-significant half point improvement in pain scores after two weeks, compared with those not receiving it.

The consumption of additional analgesics was also similar between both groups, with the spinal manipulation group taking only 18mg less of diclofenac.

Professor Peter Juni, lead investigator and head of the division of clinical epidemiology and biostatistics at the University of Bern, Switzerland, said: ‘Spinal manipulation is unlikely to result in relevant early back pain reduction in primary care patients with acute back pain.'

The study adds to mounting criticism over NICE guidelines on back pain. The controversy has already led to the British Pain Society ousting their president, Professor Paul Watson, a member of the guideline development group.

Pulse revealed last month that PCTs are struggling to keep pace with a sudden rise in back pain referrals under the new guidance, with triple digit percentage increases in some areas.

Dr Iain Gilchrist, a GP in Bishop's Stortford, Hertfordshire, and president of the Primary Care Rheumatology Society, said spinal manipulation should be kept as an option, but the study showed it was not useful for many patients.

‘It is a popular form of treatment and it seems to help some people, but by no means everyone. Occasionally we come across some patients who have been made worse by it,' he said.

Writing in the latest edition of the British Journal of General Practice this month, Professor Edzard Ernst, professor of complementary medicine at Peninsula Medical School in Exeter, said the NICE guidance had ‘serious flaws'.

‘It is uncertain whether spinal manipulation generates more benefit than harm for patients suffering from back pain,' he said.